WHAT'S NEW
Updated November 25, 2002

Health Insurance Coverage and Mental Illness

A DRADA Program Cosponsored with the Pastoral Counseling Services
Thursday, January 16, 2003, 7:00 — 9:00 P.M.
Severna Park United Methodist Church
731 Benfield Road, Severna Park, MD

You are invited to attend an educational program which will address issues regarding mental illness and insurance coverage on Thursday, January 16,
2003, from 7:00 to 9:00 P.M. Our meeting place is a short drive from Baltimore, the Washington area, or Annapolis and the Eastern Shore — just seconds off Interstate I-97. There is ample free parking.

Our program features James P. Koch, Attorney-At-Law, who presented information on this topic for us several years ago. Mr. Koch received his B.A. from Johns Hopkins University and J.D. from the University of Maryland School of Law. For more than 20 years he has represented clients in Maryland's state and federal courts. Issues that may be addressed at our
meeting include parity legislation, ERISA, coverage denials and terminations, pre-existing conditions, and Medicare/Medicaid coverage.

Everyone is welcome and there is no charge to attend. For more information, please call 410-955-4647; 202-955-5800; or visit www.drada.org.

DIRECTIONS
From Baltimore:
Take 695 East to Route 97 South toward Annapolis. After passing the Route 100 intersection move toward the right lanes and take exit 10 A (Benfield Boulevard/Severna Park). Go one mile on Benfield through two lighted intersections to Severna Park United Methodist Church on the right.

From the DC area:
Take either 95 North or the Baltimore/Washington Parkway (295 North) to Route 32 East. From 32 East, exit at Route 97 North/Baltimore. Move left to get on Route 97 North toward Baltimore. Take exit 10 Benfield Boulevard/Severna Park. Go left at signal at end of ramp (Veteran's Highway). Take first right (Benfield Boulevard) and proceed approximately one mile. Severna Park United Methodist Church will be on
your right.

From Annapolis/Eastern Shore:
From Route 50 take I-97 North toward Baltimore. Take exit 10 Benfield Boulevard/Severna Park. Go left at signal at end of ramp (Veteran's Highway). Take first right (Benfield Boulevard) and proceed approximately one mile. Severna Park United Methodist Church
will be on your right.

Summaries of the 16th annual Mood Disorders Symposium Presentations

Were you unable to attend the DRADA symposium this year?

If you were in attendance, would you like a summary of your favorite speaker presentation?

Well, you're in luck! In the summer issue of Smooth Sailing, there will be summaries of all presentations made for the 16th annual symposium. Smooth Sailing is one of the benefits of a DRADA membership. To learn more about membership click here.

J. Raymond DePaulo, Jr., M.D. Named Chairman, Johns Hopkins Medicine Department of Psychiatry - a letter from Edward Miller, M.D., CEO, Johns Hopkins Medicine and Dean, Johns Hopkins Medical Faculty

February 14, 2002

Dear Colleagues,

I am delighted to report that J. Raymond DePaulo, Jr., M.D., is the Henry Phipps Professor and new chairman of the Department of Psychiatry and Behavioral Sciences, effective February 15. With "confidence, enthusiasm and unanimity" in recommending Dr. DePaulo’s appointment, the Search Committee headed by Jack Griffin and Sol Snyder commented on his "indispensable strengths in clinical psychiatry and teaching, and his exciting vision of the future of neuropsychiatric research."

Ray DePaulo is one of the world’s foremost investigators into the genetic bases of affective disorders. His ongoing research includes genetic studies of bipolar disorder and unipolar disorder, combined brain imaging and genetic studies of bipolar families, and studies to improve the high school health curriculum on depression and other mood disorders.

Dr. DePaulo received his B.S. (Magna Cum Laude) from Xavier University in Cincinnati and his M.D. from Hopkins. After completing his internship and residency at Hopkins, he began his full-time academic career with us in 1977 as assistant professor in the Department of Psychiatry and founding director of the Affective Disorders Clinic. He rose through the ranks to become associate professor in 1983 and professor in 1993.

A member of many prestigious professional societies and editorial boards, Dr. DePaulo also has been on several advisory committees, including those of the National Depression and Manic Depression Illness Association and the National Association for Research in Schizophrenia and Depression. He is a founding member of the Depression and Related Affective Disorders Association (DRADA).

In addition to his numerous awards for research in depression and bipolar disorder, Dr. DePaulo was invited to address the World Economics Forum in Davos, Switzerland, both in 2000 and 2001, about the burden of psychiatric disease on national and global economies. He is the author of two books, more than 90 scientific articles and six educational videos on depressive illness.

During his tenure at Hopkins, Dr. DePaulo has made great contributions to the clinical management of neuropsychiatric disorders and enjoyed extensive grant support from the National Institutes of Health. Additionally, the search committee noted "his ability to inspire medical students and young investigators about the future of psychiatry."

While we look forward to Dr. DePaulo’s leadership, I know you also join me in thanking Chester Schmidt for a superb job as Interim Director of the Department of Psychiatry and Behavioral Sciences – and, of course, Paul McHugh for his quarter century at the department’s helm.

Sincerely,

Edward D. Miller, M.D.

SUMMIT ON WOMEN AND DEPRESSION: PROCEEDINGS AND RECOMMENDATIONS

A new report was just released on March 15th focusing on depression in women by the American Psychological Association. The newly released report
summarized the proceedings of a summit meeting cosponsored by the National Institute of Mental Health that focused on depression in women. Over 35
experts from a variety of disciplines were in Attendance to provide reviews of research findings on women and depression, to provide recommendations on how these findings might inform health Policy and improve clinical practice, and to produce a targeted research agenda on women and depression. Findings
in four major areas are reflected in the report: the etiology of sex and gender differences in depression; treatment and prevention of depression in
women; treatment and prevention of depression in special populations of women; and services for women with depression. The entire report is
available in pdf format at www.apa.org/pi/wpo/women&depression.pdf.
(posted on March 28th by NIMH)

Volunteers Needed for Outreach Project
DRADA needs volunteers to give presentations at Baltimore-area hospitals and day treatment programs as part of our Hospital Networking Project. The goal is to introduce patients to support groups, peer support, referral services, and other resources that DRADA has to offer. If you are interested, please call DRADA at 410-955-4647 and leave a message, or call Jennifer Ecton at 410-614-4588.

Reference Shelf: Living and Coping with Mood Disorders
Our Reference Shelf now features three new books:

" Mood Genes: Hunting for Origins of Mania and Depression" by Samuel H. Barondes, M.D.

"How You Can Survive When They're Depressed: Living and Coping with Depression Fallout" by Anne Sheffield

Support Group Leader Training

Interested in starting a mutual-help support group in your community? DRADA offers a one-day training program for prospective leaders at Johns Hopkins Hospital in Baltimore. Participants receive a training manual, materials and a deli lunch.

DRADA's next one-day training program for prospective support group leaders will be Saturday, January 18, 2003 at The Johns Hopkins Hospital in Baltimore, Maryland. Advanced registration is required. To register or for more information, call Wendy Resnick at 410-987-1156. To learn more about the program and support groups, see Support Group Leader Training.

New Washington D.C. Phone Number
The D.C. phone number has changed from 202-884-3964. The new number is 202-955-5800.

DEPRESSION AND THE BRAIN

An edited transcript of a talk by Dr. J Raymond DePaulo Jr., M.D., professor of psychiatry at Johns Hopkins University School of Medicine at a conference on March 17, 1999, sponsored by the Dana Alliance for Brain Initiatives.

As you know, I am a psychiatrist, or to put it more simply, I am a depression doctor. Because I work at Johns Hopkins, I have been able to focus on one illness, depression.

I am here to talk to you about four topics: the impact of clinical depression on patients and families, the current state of clinical care of patients with depression and manic depression (bipolar disorder), the contributions that three brain sciences (genetics, brain imaging, and pharmacology) already have made to the field, and what is needed to assure a brighter future for those afflicted by this illness.

First, I want to clarify what I mean by the term depression. When I talk about depression, I am not talking about discouragement. I remember a patient I evaluated several years ago. When I told him at the end of the evaluation he had clinical depression, he looked at me, shaking his head, as if I was from Mars, and he said 'Look, DePaulo, I know what depression is. That is when your dog dies and you feel sad. I don’t own a dog. I don't feel sad. Start over again." He had clinical depression, but the word depression was confusing to him as it confuses many others. By clinical depression I mean a set of signs and symptoms affecting not only mood, but mental and physical vitality, self esteem, self confidence, and several bodily functions.

Depression's Impact on People and Dollars
What is the impact or importance of clinical depression as compared to other diseases? The first important fact is that 15 million Americans have it. It comes in episodes, often beginning late in adolescence and reoccurring throughout the life span, if untreated. The number of people affected and the long-term course are only the beginning. In 1990, when a series of studies was done to calculate the costs of several diseases, the cost of depression in the U.S. economy was estimated at $44 billion per year.

For comparison, the estimates of the cost of coronary artery disease and of cancer were estimated at the same time. Using the same methods for calculation, the estimated cost of all coronary artery disease was almost identical to depression: $43 billion. The estimated cost to our economy from all cancers taken together was $101 billion. So, depression is enormously disruptive to the lives of our patients and their families, but it is also of economic importance for us as a society.

The World Health Organization has recently published a very extensive study on the causes of disability and the economic and social burden caused by various diseases on a worldwide basis. They found that the leading cause of disability in world today is unipolar depression (i.e., episodes of clinical depression without manic episodes). Bipolar disorder or manic depression is number six on the list. In fact, five psychiatric disorders are among the top ten causes of disability worldwide. Unipolar depression alone makes up 10 percent of all cases. In terms of their impact, these have been the most neglected diseases in medicine.

What is the current state of clinical care? It is quite different than for diseases like Huntington's disease (HD), which Dr. Gusella described. Through the genetics studies he and his colleagues have carried out, we now know much about its cause (the gene, the protein it makes, and even some aspects of the protein's function), but we still don't have a treatment for it.

In depression, just the opposite is true. We have some fairly effective antidepressant medications. Each one works in about 65 percent of patients with major depression. These breakthroughs came from pharmacology. However, we know almost nothing about the mechanism of the disease in the brain, so that when antidepressants are helpful, we don’t know why they work. Nor do we know why they fail when they fail.

SSRIs Make a Difference
The biggest watershed that pharmacology has crossed for us has been the development of the first rationally designed family of antidepressants, the selective serotonin reuptake inhibitors (SSRIs). About 20 years ago pharmacologic studies suggested that some depressions came from depletion of brain catecholamine neurotransmitters. Drugs like Serpasil deplete them and are associated with severe depressions, as Dr. Bloom noted. It was thought that other depressions were caused by a depletion of serotonin. Some pharmaceutical companies wisely set out to develop drugs which would specifically enhance the brain concentrations of those chemicals. In this country, Prozac is the drug that we know as the primary SSRI. Others were developed at the same time in Europe. We still don’t know why they work, but we have better ideas to test now.

It is a strange twist, but that is our situation today. We need to understand the brain mechanism of the disease and the mechanism of action of these drugs to advance beyond this state. Despite the availability of many new antidepressants, only 15 to 30 percent of patients with major depression and bipolar disorder are getting diagnosed and treated for it. That is a scandal.

Why does this happen? First, most depressed patients are not diagnosed. These patients often come to their doctor, but they don't know what they are coming for, and, unfortunately, many clinicians don't recognize the disorder in their patients. There are no laboratory tests to help the clinician resolve or confirm any suspicion.

Once you have diagnosed it, you can at least apply these treatments. Where are these laboratory tests going to come from? Probably genetics, but genetics, imaging, pharmacology, as I said, all work together.

The third thing is what have the contributions been from these research areas? From brain imaging studies, we have learned what brain regions are crucial for depression that comes following stroke.

Searching for the Genes
We know now that Huntington's disease involves the same brain regions, about 40 percent of patients with Huntington's disease have depression in the early stages of their illness, interestingly not so in the later stages. We now know that those brain regions that are important in post-stroke depression and in Huntington's disease are important in families with the familial forms of depression.

Genetic studies have demonstrated in twin and adoption studies that genes are important causes of many forms of depression. Finding the genes has been difficult probably because it is so common. Since depression affects 15 million Americans at any one time, the disease can't be caused by a single gene, but is more likely to be the result of an interaction of several common genes with co-occur in some individuals in some families. We know that for most people a single gene will not be sufficient as it is in Huntington's disease, where having the gene almost guarantees that you will get the disease. Depression and bipolar disorder will occur in an individual when a number of specific genes react in the absence of protective genes. To put it simply, most people with any one of these genes will not have any illness at all.

It is not a needle in a haystack, it's a haystack full of needles that we have got to sort out. We can do it and we must. An early report has recently been presented demonstrating that specific genes can predict which patient will have terrible side effects from one group of psychoactive medicines and which patients will not.

What is needed from the three big brain sciences? We need laboratory tests to help all clinicians improve in diagnosing depression and bipolar disorder. From brain imaging we need more precise localization of the brain areas and brain cells which malfunction in depression. As Dr. Phelps noted, new and more powerful ways of using brain imaging methods can monitor brain function as well as structure. Further development of these methods that will link imaging and pharmacologic experiments in the same patients is crucial.

We also need more rational drug development. That will come from not only basic pharmacology, but also from genetics where we will get blueprints of the molecules which contribute to depression.

What do we need from genetics (and this is the area where I am trying to do my best to be of help)? Fundamentally, we need the genes that predispose people to this illness. We also would be very happy to know of the genes — and we think they are there — that protect people from this illness.

The three major brain sciences, brain imaging, pharmacology, and genetics, can work together hand and glove, and when needed hand and glove and foot, to illuminate a mysterious disorder like depression.

We have come a long way. We have got a much further way to go. How would I conclude? We need much more support for the brain sciences and the clinical sciences that relate to brain diseases such as depression. That support certainly is financial, but it is also in the form of more public education about these illnesses and more scientific careers devoted to studying them.

Reprinted from "Advances in Brain Research 1999", The Charles A. Dana Foundation.

Reports in Smooth Sailing of talks at symposiums co-sponsored by DRADA.

Patient Perspectives

A Patient's Perspective - Dick Cavett

A Patient's Perspective - Robert Boorstin

A Patient's Perspective - Art Buchwald

Family Member Perspectives

A Family Member's Perspective - Wendy Baynard. M.S.W.

A Family Member's Perspective - George McGovern

Darkness Visible

Styron, William. New York: Random House, 1990. Hardback, 84 pages; also in paperback.

At DRADA’s 1989 mood disorders symposium acclaimed author William Styron spoke movingly about his experience with depression. That talk evolved into an article in Vanity Fair, which in turn, evolved into this short book. Darkness Visible is subtitled, rather dramatically, “A Memoir of Madness.” In it Styron recounts a severe depressive episode so vividly that even an incurably happy person will likely begin to comprehend his despair.

The story begins in Paris, where Styron—already clinically depressed and knowing it, but not yet in treatment—is receiving a prize for his writing. During the festivities, which “should have sparklingly restored my ego,” writes Styron, “my brain had begun to endure its familiar siege: panic and dislocation, and a sense that my thought processes were being engulfed by a toxic and unnameable tide that obliterated any enjoyable response to the living world.” He lists the problems he experiences during a dinner with friends that night as “failure to have an appetite . . . , failure of even forced laughter and, at last, virtually total failure of speech.” As his depression continues unrelieved, he contemplates suicide: “Hideous fantasies [of suicide], which cause well people to shudder, are to the deeply depressed mind what lascivious daydreams are to persons of robust sexuality.”

Styron rails against the general public’s failure to understand the seriousness of depression: “For in virtually any other serious sickness, a patient who felt similar devastation would be . . . in bed . . . His invalidism would be . . . unquestioned . . . .” But the depressed person “is thrust into the most intolerable social . . . situations [where] he must try to utter small talk . . . and, God help him, even smile.”

The word “depression,” Styron says, is “a true wimp of a word for such a major illness . . . Nonetheless, for over seventy-five years the word has slithered innocuously through the language like s slug, leaving little trace of its intrinsic malevolence and preventing, by its very insipidity, a general awareness of the horrible intensity of the disease when out of control.” And because getting it under control is not accomplished overnight, “failure of [rapid] alleviation is one of the most distressing factors of the disorder to the victim . . . .”

In addition to the narrative of his descent into depression, survival of urges to suicide, and eventual recovery, the book includes Styron’s views on the morality of suicide; the high prevalence of depression and suicide among “artistic types”; the variety of causes of depression and ways of experiencing it; and the merits of psychotherapy, psychopharmacology, and psychiatric hospitalization.

Most DRADA readers will realize that Styron’s discussion of causes and treatments reflects his own views and does not provide a balanced or comprehensive presentation of current medical knowledge. With this caveat understood, this book is highly recommended for relatives, friends, and coworkers of persons with a depressive disorder.

By Anne Maclean Heasty